How you help a mother to feed her young baby depends on
whether the mother is HIV- (negative), of unknown HIV status or HIV+ (positive).
Much research is presently being done on the feeding of babies whose mothers are
HIV+. The advice given in this topic is what nutritionists currently (in 2004)
recommend (see WHO/UNICEF/UNFPA/UNAIDS. 2003. HIV and infant feeding
listed in Appendix 3).

BOX 10 · EXCLUSIVE
BREASTFEEDING

Exclusive breastfeeding means an infant receives
only breastmilk from the mother or a wet nurse, or expressed breastmilk,
and no other liquids or solids except drops or syrups consisting of vitamins,
mineral supplements or medicines.

If the mother is HIV- or of unknown
HIV status

Most babies should breastfeed exclusively for six
months

Advise the mother to exclusively breastfeed until the baby is
six months (180 days) old.

Breastmilk
contains all the nutrients a full-term baby needs for the first six months of
life. It provides enough water even in hot weather and is the safest source of
water.

Exclusive breastfeeding
reduces the risk of diarrhoea and other infections. Giving any other food or
drink increases the risk of diarrhoea.

Exclusive breastfeeding means
the mother is unlikely to become pregnant.

Breastmilk provides all the food and water young babies
need

Ways to encourage exclusive breastfeeding include:

helping the baby
to start suckling within one hour of birth - the mother and baby should be in
skin contact immediately after birth;

if necessary, explaining why
colostrum is an essential food for newborn babies. Colostrum contains high
levels of vitamin A and anti-infective factors that protect newborns from
disease. Giving colostrum is like giving a first immunization. If a family has a
wrong belief about colostrum (e.g. it is dirty), help them to understand it is
safe, and is the perfect food for their new baby;

checking that the baby is
suckling correctly (see Figure 9);

if necessary, explaining why
families should not give baby any other food or drink (even traditional
drinks);

advising the mother to feed
on demand (when the baby wants to feed) at least 8-10 times over 24
hours, and let the baby suckle for as long as he or she wants day and
night;

teaching the mother how to
express and store her milk if she is away from her baby for more than three
hours;

referring the mother to a
local breastfeeding support group if there is one.

Figure 9. Suckling in the correct
position

Babys body is turned towards mother, the chin touches
mothers breast, the mouth is wide open and both lips are turned outwards.
More areola is above than below babys mouth. The baby takes slow deep
sucks and you can hear the baby swallowing.

Colostrum is the best and safest food for
newborns

Also advise families that breastfeeding mothers
need:

extra food (the
equivalent of one extra small meal a day). They especially need more meat,
poultry, offal and fish, and more vegetables and fruits;

enough drink so they are not
thirsty;

more rest if
possible.

Make sure mothers know that HIV can be passed to their babies
through breastmilk and how to avoid that their babies become infected.

If the mother is HIV+

Explain the risks and benefits of breastfeeding and
replacement feeding to HIV+ mothers and their partners before the baby is
born

While the mother is still pregnant:

explain to her the
risk of the virus being passed to her baby through breastmilk;

explain and discuss the risks
and benefits of exclusive breastfeeding and of replacement feeding, and the
risks of feeding breastmilk with other foods (see Box 11, page 56).

Replacement feeding means feeding a child who is not receiving
breastmilk with a diet that provides all the nutrients the child needs. During
the first six months this should be a suitable breastmilk substitute, such as
commercial or home-made formula.

BOX 11 · RISKS AND
BENEFITS OF DIFFERENT WAYS OF INFANT FEEDING

Exclusive breastfeeding

It gives immunity
from other infections, is the best source of nutrients and safe water, reduces
the risk of pregnancy and prevents the possible stigma of not
breastfeeding.

There is a risk of passing HIV
to the baby but this is lower if:

- the mother gives no other food or
drink;- the mother does not have cracked nipples or mastitis, or is not
clinically ill with AIDS;- the baby does not have sores or thrush in the
mouth.

Replacement feeding

There is no risk
of passing HIV to the baby.

There is a high risk of
diarrhoea and other infections if the family lacks the resources to buy and
prepare other milk feeds safely.

There is a risk that the
caregiver will prepare the feed incorrectly (e.g. overdilute it) so that the
child becomes malnourished.

There is the possibility of
stigma and of others knowing the mothers HIV status.

Replacement feeds should only be given where they are
acceptable, feasible, affordable, sustainable and safe.

Feeding both breastmilk and breastmilk
substitutes

There is a higher
risk of passing HIV to the baby than with exclusive breastfeeding.

There is a risk of other
infections and malnutrition if breastmilk substitutes are not prepared safely
and correctly.

When a HIV+ mother has decided how to feed her baby, give her
support and advice. If the mother agrees, try to talk with relatives (e.g. her
husband, partner and/or mother) so they can also support and help her.

If the mother decides to breastfeed:

strongly advise
her to start exclusive breastfeeding immediately after birth, and not to give
any other food or drink. Advise her to exclusively breastfeed for the first few
months and up to six months. When she wants to stop breastfeeding, she should do
this when the family is able to give suitable replacement feeds;

take time to explain the risks
of feeding breastmilk with other foods;

counsel her on how to
exclusively breastfeed (see above);

advise her to immediately seek
health care if she has cracked nipples, engorged breasts or if her baby has
sores or thrush in the mouth;

counsel, in advance, on how to
stop breastfeeding as this should be done at an earlier age and over a shorter
period than usual, and the mother needs to plan for this change (see Box
12);

weigh the baby at least
monthly to monitor his or her growth.

BOX 12 · STOPPING
EXCLUSIVE BREASTFEEDING FOR HIV+ MOTHERS

HIV+ mothers should stop breastfeeding over a shorter
period than usual (i.e. the change-over period from exclusive breastfeeding
to replacement feeding should last only about two weeks or less). This is
because the baby is at higher risk of HIV infection during the change-over
period.

However, ceasing breastfeeding over a short period increases
the risk of difficulties such as mastitis and breast abscesses, and objections
from families - and the babies may become distressed and lose their
appetites.

To help mothers and babies during the change-over period,
health workers can:

show a mother how
to express her breastmilk and then heat-treat it (heattreating destroys the HIV
virus). This reduces the risk of engorgement for the mother and allows the baby
to continue receiving breastmilk while becoming used to the tastes of
replacement feeds and to cup feeding. To heat-treat breastmilk, put the milk in
a small pot, heat until the milk boils and then put the pot into a container of
cold water so the milk cools quickly;

advise a mother (and her
relatives if possible) on suitable replacement feeds and how to prepare them.
Babies aged less than six months should receive only breastmilk substitutes
(home-made or commercial infant formula) or heattreated breastmilk. After that
they should also have complementary feeds (see Topic 7);

tell a mother to give extra
attention and love to her baby and to give replacement feeds or expressed
heat-treated breastmilk herself;

advise a mother to seek health
care immediately if she has any signs of mastitis and/or sore nipples;

if appropriate, explain to
relatives the reasons for ceasing breastfeeding earlier than
usual.

If the mother decides not to breastfeed:

advise the mother
(or other caregiver) not to give any breastmilk (unless expressed and
heat-treated). Emphasize the risks of giving both breastmilk and other
foods;

check that the family has the
resources and skills for making and giving replacement feeds;

show the mother how to prepare
the feeds and how to feed with a cup. Emphasize the need for good hygiene and
for diluting the milk correctly. Explain the risks of using a bottle (e.g. they
are difficult to clean and so increase the risk of diarrhoea);

watch the mother prepare and
give a feed and correct any mistakes. Try to do this in her own home using her
own equipment;

encourage the mother to feed
the baby herself and to cuddle him or her as often as possible;

if appropriate, talk with the
mothers relatives (e.g. her partner or mother) and explain what they can
do to support and help her;

tell the family to take the
baby quickly to a health worker if there are any feeding or health
problems.

Monitoring babys
weight

Babies aged 0-6
months should be weighed at least monthly. Plot the weights on a growth chart
and make sure the mother or caregiver understands the growth curve (see Topic
11, page 89). This is especially important for children whose mothers are
HIV+.

Give any necessary advice and
support on feeding and care (see Topic 11). Topic 7 explains when to start
complementary foods.

Give vitamin A supplements
according to national protocols.

SHARING THIS INFORMATION

Before sharing this information with families, you may need
to:

1. Find out. How local babies aged 0-6
months are fed. Whether mothers exclusively breastfeed, and if so, for how long.
If not, which other foods, water or other drinks are given. What the blocks to
exclusive breastfeeding for six months are. How women who are HIV+ feed their
babies. What their knowledge of the risks and benefits of different feeding
methods is. Who decides how babies are fed. What advice and resources are needed
by mothers who decide not to breastfeed. Which breastmilk substitutes are
available locally and what their costs are. What breastfeeding women do if they
have breastfeeding problems, such as sore nipples or engorged breasts, or if
their babies have thrush.

2. Prioritize. Decide which information is most
important to share. This may depend on whether you are communicating with
groups of mothers or parents, with individual HIV+ mothers, with mothers who are
HIV- or whose status is unknown, or with traditional midwives.

3. Decide whom to reach. For example: mothers, other
caregivers and, if appropriate, their partners and other relatives; traditional
midwives.

4. Choose communication methods. For example:
individual counselling and group discussions at antenatal and postnatal clinics,
in maternity wards and at young child clinics; demonstrations of suckling
position, replacement feeding and heat-treating expressed breastmilk.

Examples of questions to start a discussion(choose
only a few questions that deal with the information families need
most)

What is exclusive breastfeeding? Why do we recommend exclusive
breastfeeding?

Why is colostrum an excellent food for newborns? Do we give
colostrum to our babies? If not, why not?

Do breastfed babies need extra water?

What foods or drinks other than breastmilk do we sometimes
give young babies? Why? Could we stop doing this?

What should women who have sore nipples or engorged breasts
do?

Do breastfeeding women need extra food? Which foods are good
for breastfeeding women?

Discuss the feeding of babies of HIV+ mothers only if a
group wants to. Do this in a sensitive way. Otherwise counsel mothers
individually.

Can the virus be passed to a baby through breastmilk? Explain
that the risk may be less if a baby is exclusively breastfed.

What are the dangers of replacement feeding? Explain the risks
and benefits of both exclusive breastfeeding and replacement feeding. Explain
the risks of giving both breastmilk and breastmilk substitutes.

How can breastmilk be made safe during the time that a mother
is changing from exclusive breastfeeding to replacement feeds? Explain why and
how to express and heat-treat breastmilk.

If replacement feeding occurs in the area

Which breastmilk substitutes are available and used here? How
much do they cost? Do mothers know how to prepare them in a safe and hygienic
way? Are they culturally acceptable?

Why is it dangerous to feed with a bottle? Do women know how
to feed with a cup?

Demonstrate preparing and giving a feed using a breastmilk
substitute that local families can afford.